Increasing North Carolina's Workforce Capacity for Prescribing Buprenorphine Products.

BACKGROUND Inadequate access to opioid use disorder (OUD) treatment is a public health concern. Rates of opioid-related poisoning deaths are increasing in North Carolina and access to OUD treatment is especially sparse in rural areas. DEA-X-waivered providers that can prescribe buprenorphine as a medication for opioid use disorder (MOUD) play an essential role in treating OUD. Increased workforce capacity to treat OUD in an evidence-based, equitable, and patient-centered way is needed. Gaps persist in continuing professional education and academic training.METHODS Description of an interdisciplinary training team effort to engage medical residencies and advanced practice provider (APP) programs across North Carolina in a set of subsidized trainings about substance use disorder treatment and medication-assisted treatment (MAT), with the goal of increasing capacity to administer MOUD, based on each program's needs. Uptake was independently evaluated.RESULTS Engagement exceeded initial goals: 72 unique trainings related to MAT were administered to 1512 providers from 30 residency and 7 APP programs. By the end of the grant period, 902 participants completed a training required to obtain a DEA-X waiver. Evaluation of training uptake identified facilitators and barriers specific to residents and APP trainees.LIMITATIONS Limitations included difficulty coordinating training with existing didactic and clinical schedules during the project time frame and challenges identifying implementation leaders at training sites.CONCLUSION This project highlights a successful and potentially replicable approach to offering structured MAT capacity-building training in combination with technical assistance (TA) within medical education programs.

Piloting the Mobile Medical Milestones Application (M3App©): A Multi-Institution Evaluation.

BACKGROUND AND OBJECTIVES: Competency-based evaluation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones requires the development of new evaluation tools that can better capture learners' behavior. This study describes the implementation and initial assessment of an innovative point-of-care mobile application, the M3App,© linked to the Family Medicine Milestones. METHODS: Seven family medicine residency programs in North Carolina implemented the M3App.© Program faculty and residents were surveyed prior to implementation regarding current evaluation methods and their quality and use and acceptability of electronic evaluation tools. Surveys were repeated after implementation for comparison. RESULTS: All seven programs successfully implemented the M3App. Most faculty members found the tool well designed, easy to use, beneficial to the quality and efficiency of feedback they provide, and to their knowledge of Milestones. Residents reported significant increases in the volume and quality of written feedback they receive. CONCLUSIONS: The M3App provides an efficient, convenient tool for assessing Milestones that can improve the quantity and quality of feedback residents receive from faculty. Improved faculty perception of knowledge of Milestones after M3App implementation suggests that the tool is also effective for faculty development.

Learnings From the Pilot Implementation of Mobile Medical Milestones Application.

BACKGROUND: Implementation of the educational milestones benefits from mobile technology that facilitates ready assessments in the clinical environment. We developed a point-of-care resident evaluation tool, the Mobile Medical Milestones Application (M3App), and piloted it in 8 North Carolina family medicine residency programs. OBJECTIVE: We sought to examine variations we found in the use of the tool across programs and explored the experiences of program directors, faculty, and residents to better understand the perceived benefits and challenges of implementing the new tool. METHODS: Residents and faculty completed presurveys and postsurveys about the tool and the evaluation process in their program. Program directors were interviewed individually. Interviews and open-ended survey responses were analyzed and coded using the constant comparative method, and responses were tabulated under themes. RESULTS: Common perceptions included increased data collection, enhanced efficiency, and increased perceived quality of the information gathered with the M3App. Residents appreciated the timely, high-quality feedback they received. Faculty reported becoming more comfortable with the tool over time, and a more favorable evaluation of the tool was associated with higher utilization. Program directors reported improvements in faculty knowledge of the milestones and resident satisfaction with feedback. CONCLUSIONS: Faculty and residents credited the M3App with improving the quality and efficiency of resident feedback. Residents appreciated the frequency, proximity, and specificity of feedback, and faculty reported the app improved their familiarity with the milestones. Implementation challenges included lack of a physician champion and competing demands on faculty time.

Prenatal care, pregnancy outcomes, and postpartum birth control plans among pregnant women with opiate addictions.

OBJECTIVES: To describe how effectively we provided adequate prenatal care and postpartum contraception to prevent repeat, unintended pregnancies to women using opiates or medication maintenance therapy (MMT) during pregnancy. METHODS: We conducted a retrospective chart review of 94 women using opiates or MMT during 96 pregnancies while receiving prenatal care in the regional high-risk maternity care clinic between July 2010 and June 2012. We examined prenatal care usage, birth outcomes, and postpartum contraception using χ(2), Kruskal-Wallis, and binary logistic regression modeling. RESULTS: Patients were predominately white (93.6%), multiparous (75.5%), and in their 20s; 71 (74%) used MMT and 25 (26%) used prescribed or illicit opiates. Fewer than half (44% [46.2%]) received any documented prenatal counseling about postpartum contraception. Sixteen (17%) babies were premature. Sixty-four (66.7%) infants were diagnosed as having neonatal abstinence syndrome (NAS). Only 42 (43.8%) women attended their postpartum visits. Overall, 60 (62.5%) women received postpartum contraception. The only significant predictors of postpartum contraception use were preterm birth and postpartum appointment attendance. CONCLUSIONS: Alternative strategies for providing postpartum care should be explored because women using opiates or MMT during pregnancy are significantly more likely to use postpartum contraception if they attend their postpartum appointments.

Pilot Study of Implementation of an Internet-Based Depression Prevention Intervention (CATCH-IT) for Adolescents in 12 US Primary Care Practices: Clinical and Management/Organizational Behavioral Perspectives.

OBJECTIVE: To explore the implementation of CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral Humanistic and Interpersonal Training), an Internet-based depression intervention program in 12 primary care sites, occurring as part of a randomized clinical trial comparing 2 versions of the intervention (motivational interview + Internet program versus brief advice + Internet program) in 83 adolescents aged 14 to 21 years recruited from February 1, 2007, to November 31, 2007. METHOD: The CATCH-IT intervention model consists of primary care screening to assess risk, a primary care physician interview to encourage participation, and 14 online modules of Internet training to teach adolescents how to reduce behaviors that increase vulnerability to depressive disorders. Specifically, we evaluated this program from both a management/organizational behavioral perspective (provider attitudes and demonstrated competence) and a clinical outcomes perspective (depressed mood scores) using the RE-AIM model (Reach, Efficacy, Adoption, Implementation, and Maintenance of the intervention). RESULTS: While results varied by clinic, overall, clinics demonstrated satisfactory reach, efficacy, adoption, implementation, and maintenance of the CATCH-IT depression prevention program. Measures of program implementation and management predicted clinical outcomes at practices in exploratory analyses. CONCLUSION: Multidisciplinary approaches may be essential to evaluating the impact of complex interventions to prevent depression in community settings. Primary care physicians and nurses can use Internet-based programs to create a feasible and cost-effective model for the prevention of mental disorders in adolescents in primary care settings. TRIAL REGISTRATION: ClinicalTrials.gov identifiers: NCT00152529 and NCT00145912.

Randomized controlled trial of primary care physician motivational interviewing versus brief advice to engage adolescents with an Internet-based depression prevention intervention: 6-month outcomes and predictors of improvement.

We believe that primary care physicians could play a key role in engaging youth with a depression prevention intervention. We developed CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral and Interpersonal Training), which is an adolescent Internet-based behavior change model. We conducted a randomized comparison of two approaches in engaging adolescents with the Internet intervention: primary care physician (PCP) motivational interview + CATCH-IT Internet program (MI) vs PCP brief advice + CATCH-IT Internet program (BA). The participants (N = 84) were recruited by screening for risk of depression in 13 primary care practices. We compared depressive disorder outcomes between groups and within groups over 6 months and examined the potential predictors and moderators of outcomes across both study arms. Depressive symptom scores declined from baseline to 6 weeks with these statistically significant reductions sustained at the 6 months follow-up in both groups. No significant interactions with treatment condition were found. However, by 6 months, the MI group demonstrated significantly fewer depressive episodes and reported less hopelessness as compared with the BA group. Hierarchical linear modeling regressions showed higher ratings of ease of use of the Internet program predicting lower depressive symptom levels over 6 months. In conclusion, a primary care/Internet-based intervention model among adolescents demonstrated reductions in depressed mood over 6 months and may result in fewer depressive episodes.

Pruritic erythematous maculopapular rash.

A trip to the beach left this patient with an unusual rash where his bathing suit had been.

Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes.

OBJECTIVE: The authors sought to evaluate 2 approaches with varying time and complexity in engaging adolescents with an Internet-based preventive intervention for depression in primary care. The authors conducted a randomized controlled trial comparing primary care physician motivational interview (MI, 5-10 minutes) + Internet program versus brief advice (BA, 1-2 minutes) + Internet program. SETTING: Adolescent primary care patients in the United States, aged 14 to 21 years. PARTICIPANTS: Eighty-four individuals (40% non-white) at increased risk for depressive disorders (subthreshold depressed mood >3-4 weeks) were randomly assigned to either the MI group (n = 43) or the BA group (n = 40). MAIN OUTCOME MEASURES: Patient Health Questionnaire-Adolescent and Center for Epidemiologic Studies Depression Scale (CES-D). RESULTS: Both groups substantially engaged the Internet site (MI, 90.7% vs BA 77.5%). For both groups, CES-D-10 scores declined (MI, 24.0 to 17.0, p < .001; BA, 25.2 to 15.5, p < .001). The percentage of those with clinically significant depression symptoms based on CES-D-10 scores declined in both groups from baseline to 12 weeks, (MI, 52% to 12%, p < .001; BA, 50% to 15%, p < .001). The MI group demonstrated declines in self-harm thoughts and hopelessness and was significantly less likely than the BA group to experience a depressive episode (4.65% vs 22.5%, p = .023) or to report hopelessness (MI group of 2% vs 15% for the BA group, p = .044) by 12 weeks. CONCLUSIONS: An Internet-based prevention program in primary care is associated with declines in depressed mood and the likelihood of having clinical depression symptom levels in both groups. Motivational interviewing in combination with an Internet behavior change program may reduce the likelihood of experiencing a depressive episode and hopelessness.

Adolescent Dose and Ratings of an Internet-Based Depression Prevention Program: A Randomized Trial of Primary Care Physician Brief Advice versus a Motivational Interview.

BACKGROUND: Internet-based interventions for education and behavior change have proliferated, but most adolescents may not be sufficiently motivated to engage in Internet-based behavior change interventions. We sought to determine how two different forms of primary care physician engagement, brief advice (BA) versus motivational interview (MI), could enhance participation outcomes in an Internet-based depression prevention intervention. METHODS: Eighty-three adolescents at risk for developing major depression were recruited by screening in primary care and randomized to two groups: BA (1-2 minutes) + Internet program versus MI (10-15 minutes) + Internet program. We compared measures of participation and satisfaction for the two groups for a minimum of 12 months after enrollment. RESULTS: Both groups engaged the site actively (MI: 90% versus BA: 78%, p=0.12). MI had significantly higher levels of engagement than BA for measures including total time on site (143.7 minutes versus 100.2 minutes, p=0.03), number of sessions (8.16 versus 6.00, p=0.04), longer duration of session activity on Internet site (46.2 days versus 29.34 days, p=0.04), and with more characters typed into exercises (3532 versus 2004, p=0.01). Adolescents in the MI group reported higher trust in their physician (4.18 versus 3.74, p=0.05) and greater satisfaction with the Internet-based component (7.92 versus 6.66, p=0.01). CONCLUSIONS: Primary care engagement, particularly using motivational interviewing, may increase Internet use dose, and some elements enhance and intensify adolescent use of an Internet-based intervention over a one to two month period. Primary care engagement may be a useful method to facilitate adolescent involvement in preventive mental health interventions.

Integrative internet-based depression prevention for adolescents: a randomized clinical trial in primary care for vulnerability and protective factors.

BACKGROUND: Adolescent depression is both a major public health and clinical problem, yet primary care physicians have limited intervention options. We developed two versions of an Internet-based behavioral intervention to prevent the onset of major depression and compared them in a randomized clinical trial in 13 US primary care practices. METHODS: We enrolled 84 adolescents at risk for developing major depression and randomly assigned them to two groups: brief advice (BA; 1-2 minutes) + Internet program versus motivational interview (MI; 5-15 minutes) + Internet program. We compared pre/post changes and between group differences for protective and vulnerability factors (individual, family, school and peer). RESULTS: Compared with pre-study values, both groups demonstrated declines in depressed mood; [MI: 21.2 to 16.74 (p < 0.01), BA: 23.34 to 16.92 (p < 0.001)]. Similarly, both groups demonstrated increases in social support by peers [MI: 8.6 to 12.1 (p = 0.002), BA: 7.10 to 12.5 (p < 0.001)] and reductions in depression related impairment in school [MI: 2.26 to 1.76 (p = 0.06), BA: 2.16 to 1.93 (p = 0.07)]. CONCLUSIONS: Two forms of a primary care/Internet-based behavioral intervention to prevent adolescent depression may lower depressed mood and strengthen some protective factors for depression.